Antisocial Personality Disorder Treatment

Break Free From Passive Aggression

Break Free From Passive Aggression

This guide is meant to be of use for anyone who is keen on developing a better understanding of PAB, to help/support concerned people to discover various methods for helping others, also, to serve passive aggressive people as a tool for self-help.

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Antisocial Personality Disorder Malingering and Factitious Disorders

Common physician reactions to a patient with antisocial personality disorder are feelings of being used, exploited, or deceived. This can lead to physician anger and wishes to be free of the patient, uncover lies, and punish or imprison the patient. These patients fear that they will become vulnerable, lose respect or admiration from others, and become easy prey to manipulation when they become ill. They expect to be exploited, demeaned, or humiliated. Like the narcissistic patient, they often have low self-esteem, excessive self-love, compensatory feelings of superiority, grandiosity, recklessness, emotional shallowness, and show a lack of concern for others. They often react to medical care with entitled demands for special treatment. When caught in dishonesty, they may angrily attack or devalue the physician. They may resort to other psychopathic manipulations of deception, lying, cheating, or stealing. In fact, their friendly, facile, slick, superficial charm, and intelligent...

Is the Disorder Familial

In a relatively large study of 609 mood-disordered probands and 2,216 first-degree relatives, Andreasen et al. (1986) confirmed the results from previous validity studies of the family history method. Relative to the family study method, rates of illness in relatives were always underestimated by the family history method using the FH-RDC. One key exception was the diagnosis of antisocial personality The family history rate of this disorder was three times greater than the direct interview estimate. Thus, it may be that the family history method is more valid than direct interview when the disorder in question has a pejorative connotation. Kosten, Anton, and Rounsaville (1992) examined the validity of the family history method for five diagnoses used in a family study of opiate addiction depression, anxiety, antisocial personality, alcoholism, and drug abuse. For diagnosing family members, the sensitivities were uniformly low, ranging from 6 to 39 . Specificities were greater than 95...

The Patient with Posttraumatic Stress Disorder

Many trauma-related disorders have been recognized and include brief reactive psychosis, multiple personality disorder, dissociative fugue, dissociative amnesia, conversion disorder, depersonalization disorder, dream anxiety disorder, summarization disorder, borderline personality disorder, and antisocial personality disorder. Many other trauma-related disorders have been postulated. These disorders and the trauma that may precede them are indicated as follows Somatization disorder early childhood abuse Borderline personality disorder early childhood trauma Antisocial personality disorder early childhood abuse

How Can Disordered Personality Be Treated

Other psychoactive medications have proven effective in personality-disordered patients who do not respond to SSRIs or neuroleptics. For instance, lithium carbonate has been shown to reduce behavioral aggression in prison inmates with a probable diagnosis of antisocial personality disorder, relative to prisoners treated with placebo (Sheard et al., 1976). On the other hand, agents that increase dopaminergic or noradrenergic activity, in addition to anxiolytics, may increase episodic dyscontrol in patients with borderline personality disorder, and so are not recommended as treatment for this group (Cowdry and Gardner, 1988).

Postscript A View To The Future

In the case of borderline and antisocial personality disorders, anger provides an especially relevant example. The chronic experience of anger constitutes a prominent feature of the personality traits neuroticism and disagreeableness. Accordingly, angry behavior may involve both negative emotion and lack of constraint. These phenomena may stem from a combination of hyperactivity in still vaguely defined threat processing regions of the subcortex (e.g., the amygdala and medial hypothalamus) and hypoac-tivity of inhibitory regions of the ventral prefrontal cortex (Davidson et al., 2000). Certainly, in both comparative and human research, frontal lobe damage can potentiate aggressive outbursts, while treatment with serotonergic agents, which enhances resting prefrontal metabolism, can diminish their frequency (Linnoila and Charney, 2000). In addition, peptides (e.g., substance P, vasopressin) and hormones (e.g., testosterone) may prime activity in subcortical circuits related to...

Prevalence and incidence of secondary organic personality change following TBI

The association between executive deficits and antisocial behaviour (including criminality, antisocial personality disorder, and psychopathy) has received further endorsement from the meta-analysis undertaken by Morgan and Lilienfield (2000), which supported a correlational link between these phenomena. They noted a moderate to large effect size (0.62) between the two, and the relationship was not moderated by age, gender, level of intelligence, or ethnicity. They noted their largest effect size was observed with the Porteus mazes test and the smallest with the Stroop test. The second and third cases described by Labbate et al. (1997) again prove interesting. The second case involved an initial presentation of a man with antisocial personality disorder, including an extensive forensic history involving incarceration for a hit-and-run offence, theft during his youth, heavy drinking, and a dishonorable discharge from the navy, featured complete remission of his sociopathic tendencies...

Are Temper Problems Or Aggression Associated With

Antisocial personality disorders, because the former typically assume responsibility for their actions, espouse moral or religious convictions, and feel sincere remorse about the consequences of their aggressive behavior. The neurobiology of interictal aggression may involve pathologic activation of the amygdaloid complex. Figure 7.3 summarizes some of the clinical features of aggression in TLE.

Diagnostic Considerations

Although psychotic disorders, severe mood disorders, and cognitive impairments represent the most common diagnoses associated with a finding of trial incompetency, a less severe diagnosis could potentially render a defendant incompetent. However, the examiner must understand that many defendants may feel sad or anxious about their legal situation and such adjustment reactions are not usually of the type or severity that actually impairs a defendant's ability to participate in the legal process. Likewise, personality disorders alone are not typically considered as a predicate diagnosis responsible for rendering a defendant trial incompetent. For example, a defendant with antisocial personality disorder who threatens his attorney and

Antisocial Impulsive And Borderlinenarcissistic Trends

The full range of personality disorders may be encouraged under conditions of cultural disintegration and rapid change. One reason for this may involve the loss of family cohesiveness, and the failure of children to receive necessary amounts of nurturance and consistent emotional support. Out of this comes a family structure that is virtually opposite to the traditional Confucian family that stresses structure, rules, cohesion, and marital stability. Although tensions can arise in a Confucian family, its supports and networks are able to buffer most encounters with adversity. To illustrate this point, cross-cultural research related to antisocial personality disorder shows that this form of psychopathology is rare or is nonexistent in cultures that have a Confucian family structure.50 According to some thinkers, the increasing prevalence of personality disorders and related forms of psychopathology is due to the combined effects of family and community breakdown. Temperamentally...

Other Mental Disorders

Possible associations between the norm-breaking behavior of people who could be diagnosed with antisocial personality disorder and creativity have been mentioned above there is conceptual overlap between a norm-breaking lifestyle, genre-busting creativity, unconventional and ground-breaking artistic products. There have also been associations suggested with narcissistic personality disorder, with the argument that to feel one's creative work is valuable and worth showing to the wider world it is necessary to have at least some narcissistic characteristics, such as belief in one's own worth, grandiosity, and

Models of Malingering Behavior

The criminological model focuses on multiple aspects of an individual's bad character and bad behavior, namely, a bad person (antisocial personality disorder), in bad circumstances (legal difficulties), who is performing badly (uncooperative) (Rogers 1997, p. 7). Rogers (2008, p. 9) indicated that the DSM classifications (1980, 1987, 1994, 2000) have adopted the criminological model to explain the primary motivation for malingering, but w hen DSM indices are evaluated in a criminal forensic setting, they are wrong four out of five times. According to Rogers (2008, p. 9), the DSM indicators should not be used even as a screen for potential malingering because they produce an unacceptable error rate. That being said, other studies have examined the relationship between psychopathy and malingering and lend some support to the criminological model. Gacono and colleagues (1995) compared hospitalized insanity acquitees who had successfully malingered mental illness to insanity acquitees who...

Personality and Malingering

The presence of antisocial personality disorder Clark (1997) has questioned the utility of singling out evaluees with antisocial personality disorder. He suggests that these individuals are simply more likely to be involved in adversarial situations in which it would benefit them to malinger, for example, if facing criminal charges. Edens and colleagues (2000) endorsed a contrary opinion, stating that results of their study lend support to the position that the relationship between psychopathic personality features and malingering is not exclusively a function of an increased likelihood that dissimulation will occur in forensic contexts (p. 293). They concluded that psychopathic traits are associated with attitudes that may be conducive to engaging in malingering in forensic settings. in a variety of symptom exaggeration behaviors. Limiting the consideration of malingering only to individuals with diagnosable antisocial personality disorder will result in significant underdetection of...

Comorbidity and Bipolar Disorders

The ECA study (Regier et al., 1990) reported that the Bipolar I group had a prevalence of substance abuse of 60.7 . The ECA investigators suggested that a high degree of comorbidity in bipolar disorders greatly complicates treatment. Interestingly, the ECA Study (Helzer and Pryzbeck, 1988) reported that the prevalence of comorbid alcoholism in mania was three times that in major depression. Furthermore, the likelihood (odds ratio) of an individual with bipolar disorder having a substance use disorder was 6.6 times greater than that of the general population. The only diagnosis that had a higher ratio than mania was antisocial personality disorder. Tohen et al. (2000) found in a treatment-based sample that the comorbidiy of substance use disorder in a cohort of first episode mania patient to be 17.3 . This finding suggests that in most cases the sequence of comorbid substance use disorder appears after the onset of bipolar disorder.

Pretrial Dispositions Case Vignette

A young man arrested and jailed in connection with an apparent homicide was referred for a forensic consultation to address competency to stand trial and the need for psychiatric hospitalization. Anamnesis revealed that he did not have a significant history of assaulting people. However, he had tortured and killed cats and dogs over the years for sadistic pleasure. Close relatives confirmed cruelty to animals. He explained the homicide as an extension of his acts of cruelty to animals, motivated by pleasure, not by passion or personal gain. Diagnoses included antisocial personality disorder and malingering. On the basis of these diagnoses, hospitalization was not recommended.

True Prevalence Studies

Tered the Personality Diagnostic Questionnaire (Hyler, 1983) to their subjects (Zimmerman and Coryell, 1990). Prevalence rates were fairly similar, but the PDQ produced higher rates of schizotypal, compulsive, dependent, and borderline personality disorders. The SIDP yielded higher rates of antisocial and passive-aggressive personality disorders. More individuals were diagnosed with a personality disorder by the SIDP, but the PDQ diagnosed multiple personality disorders more often. The results of the PDQ are not tabulated separately because the same sample was utilized for both instruments. Casey and Tyrer (1986) carried out a study of 200 randomly selected community residents in the United Kingdom. They administered the Present State Examination (9th edition) (Wing et al., 1974) for axis I disorders and the Personality Assessment Schedule (PAS Tyrer et al., 1979) for the assessment of personality disorders. The PAS obtains information from an informant as well as the subject. Ordinal...

Prevalence of Specific Dsmiii Dsmiiir or Dsmiv Personality Disorders

In this section, each of the personality disorders will be presented, starting with the essential features of the disorder according to the DSM-IV criteria published by the American Psychiatric Association in 1994. Available data about prevalence in clinical and nonclinical populations will be presented. For several personality disorders, such as antisocial personality disorder, there are a number of studies that have reported prevalence. For many of the personality disorders, however, there have been very few reports of true prevalence. The length of each section is somewhat proportional to the amount of epidemiological data that is available about the disorder. In some cases a single study provided data on a number of individual personality disorders. To avoid redundancy, the methodology of the study is mentioned only once. Antisocial Personality Disorder . The essential feature of antisocial personality disorder is a ''pervasive pattern of disregard for and violation of the rights...

Models of Personality Disorder

The issue of categorical versus dimensional approaches. Research on etiology and pathophysiology may be more promising for adducing the type of evidence required. For example, data from genetic studies might shed light on whether factors contributing to conscientiousness and neuroticism in the general population are responsible for the occurrence of compulsive personality disorder. Another example of such an approach would be to determine whether the relationship between MAO activity and sensation seeking seen in normal populations could predict risk for antisocial personality disorder. A delineation of relationships between dimensions of normal personality and personality disorders is an important step towards acquiring the knowledge required to create a diagnostic system that accurately reflects the nature of personality disorders.

The Role of Other Factors

Sensation-seeking or the tendency to seek novel, varied, complex, and intense sensations and experiences and the willingness to take risks for the sake of such experiences is a personality trait linked to borderline and antisocial personality disorders, as well as to creativity via a preference for complexity and abstraction in art and a tendency for divergent thinking. It may also predispose creative individuals to disinhibition and thrill and adventure seeking social drinking, experimentation with drugs, and a liking for parties, casual sex, and other risk-taking, impulsive, and self-destructive behaviors which, in extreme cases, may lead to suicide.

Comorbidity and Diagnostic Overlap

Bollinger et al. (2000) examined the prevalence of personality disorders in combat veterans diagnosed with post-traumatic stress disorder. The personality disorders were assessed using the Structured Clinical Interview for DSM-III Personality Disorders nearly 80 of the sample received a diagnosis of at least one personality disorder, with 29.9 receiving a diagnosis of one, 21.5 receiving a diagnosis of two, 15.9 receiving a diagnosis of three and 12.1 receiving a diagnosis of four or more. The most frequent diagnoses were avoidant, paranoid, obsessive - compulsive and antisocial personality disorder.

Parental Psychopathology

Studies have consistently found that psychopathology in parents is associated with mental disorders in offspring (Angold and Costello, 1995b). Of course, without adoption study methodology, it is extremely difficult to separate the genetic effect from the environmental effect when studying the impact of parental psychopathol-ogy. Nevertheless, it is informative to note findings that document the association between parent and offspring mental illness. For instance, it is a well-replicated finding that children of parents with substance use disorders are at increased risk for delinquency (West and Prinz, 1987) and alcohol use themselves (Jackson, 1997 Day, 1995a, b). Also, it was found that parental alcoholism was associated with attention deficit hyperactivity disorder, and conduct disorder, while antisocial personality disorder plus alcoholism was associated with oppositional-defiant disorder, adjusting for gender, age, and socioeconomic status (Kuperman et al., 1999).

What Are Personality Disorders

Other differences may involve culture specificity. For instance, a lower incidence of antisocial personality disorder has been reported in some (e.g., China and Japan) but not all (e.g., Korea) Asian countries (Lee et al., 1987). Of course, these differences also raise the possibility that culturally biased value judgments influence the definition of personality disorder criteria. Despite the heuristic and descriptive utility of DSM-IV personality disorder diagnoses in medical settings, researchers have noted several shortcomings of these categorical diagnostic schemes. First, although the DSM-IV places personality disorders on a separate axis from other psychiatric disorders (Axis I), personality disorders often co-occur with other psychiatric disorders, and often do so in predictable ways (Dolan-Sewell et al., 2001). For instance, people with antisocial personality disorder are more likely to also receive a diagnosis of substance dependence. Second, although the DSM describes...

Comorbidity of Personality and Somatoform Disorders

Intentional production or feigning of physical signs or psychological symptoms, motivated by a desire to assume the sick role, with no other secondary gain in evidence. Factitious disorder is often comor-bid with antisocial personality disorder. Intentional production or feigning of physical or psychological illness, motivated by secondary gain (e.g., monetary disability , avoid the military, procure drugs). Malingering is often comorbid with antisocial personality disorder. compulsive requests for medical care. Clinically, these disorders have overlapping features with obsessive-compulsive disorder (OCD) and may be variants of OCD. Interestingly, all three of these disorders can be managed similarly and are somewhat responsive to treatment with antidepressants. Conversion disorders also have a long-standing connection to hysteria and more recently to Briquet's syndrome (somatization disorder) and can be understood and managed similarly to the histrionic personality disorder. Also,...

Life Course Milestones and Turning Points

Delinquency during adolescence also increases the risk of multiple psychiatric disorders during adulthood. Using data from a sample of British women who were followed from birth though age 52, Kuh, Hardy, Rodgers, and Wadsworth (2002) report that adolescent delinquency predicted major depressive disorder in middle age. Similarly, Hagan and Foster (2003) report strong associations between adolescent delinquency and adult depression for both men and women and alcoholism for men. In both studies, the effects of juvenile delinquency were estimated with a wide variety of other predictors of mental health problems statistically controlled (e.g., educational attainment, adult SES, marital status). These authors posit that juvenile delinquency is a stronger predictor of depression and substance abuse than of antisocial personality, suggesting that what is called conduct disorder in psychiatric nomenclature is a generalized risk factor for a variety of mental health problems during adulthood.

Confounding Factors

DSM-IV-TR indicates that among factors that could lead to the suspicion of malingering is the presence of antisocial personality disorder (American Psychiatric Association 2000). However, it is more likely that a potential so-ciopathic effect on disability claims is on a continuum and is parallel to symptom exaggeration and malingering (Drukteinis 2008), so the actual diagnosis of antisocial personality disorder may be less relevant. What is relevant, though, is assessing to what degree symptoms are genuine versus exaggerated, whether impairment from symptoms is substantial versus minimal, and how much can be attributed to being unable to work versus choosing not to work. Without evidence to the contrary, it is far better to explain to patients that their symptoms are inconsistent or without an adequate objective basis rather than to call them malingerers or, in effect, liars.

Frederick Erickson

In the previous window opening request example if one said, Never mind, I'll just sit here in the heat, that would change the function of the utterance from that of a request to that of a passive-aggressive complaint. When a form is chosen outside the usual choice set for a given now moment then a new function is introduced at that now moment - a function whose occurrence had not been projected by the series of functions that had been performed in the immediately prior moments. Thus the abrupt introduction of an un-projected new function changes the overall trajectory of the action sequence, and it possibly shifts the frame of that action.


More detailed analyses showed that lifetime comorbidities of specific pairs of disorders are very similar in the ECA and NCS surveys (Kessler, 1995). In both surveys, virtually all the odds-ratios (ORs) between each pair of lifetime disorders is greater than 1.0. This means that there is a positive association between the lifetime occurrences of almost all ECA and NCS disorders, demonstrating that comorbidity of psychiatric disorders is truly pervasive in the general population. There is considerable variation in the sizes of the ORs. This variation is systematic and quite consistent across the two surveys. For example, the results in both surveys show that major depression is most strongly comorbid with dysthymia and mania and least strongly comorbid with substance use disorders and antisocial personality disorder.

Substantive Findings

Compared to many axis I disorders, such as schizophrenia, there are less extensive data available on the prevalence of axis II disorders. To a great extent, this is due to a much shorter history of empirical work on most of the constructs embodied in the personality disorders. In the case of schizophrenia, the definition formulated by Kraepelin (1919 1971) shortly after the turn of the century is relatively similar to the criteria in DSM-III, DSM-III-R, and DSM-IV. In general, the personality disorders, with the possible exception of antisocial personality disorder (and its related progenitors, moral insanity, psychopathy, sociopathy, etc.), have not been the object of empirical, let alone epidemiological, research for very long. In this section a brief description of findings predating the publication of DSM-III will be provided. The largest part of this section will review findings bearing on the true prevalence'' of personality disorders, that is, rates of the disorders in...

Developmental Issues

Personality disorder diagnoses may be applied to children or adolescents in those unusual instances in which the maladaptive traits appear to be pervasive, persistent and unlikely to be limited to a particular developmental stage. However, it should be recognized that traits that appear in childhood may not persist into later adulthood (American Psychiatric Association, 1994). For diagnosis, the features of the personality disorder must be present for at least one year, with the exception of antisocial personality disorder, which cannot be diagnosed until after the age of eighteen.

Future Directions

In comparison to the major axis I disorders, there is considerably less epidemiolog-ical information about the personality disorders. There are a number of factors that have contributed to this state of affairs. Before DSM-III was published in 1980, there was less of a consensus about how to define the individual personality disorders (as well as disagreement about which disorders to include under the heading) than there was for the major axis I disorders. The most ambitious studies of true prevalence, the ECA study and the NCS, included most of the important axis I disorders, but only antisocial personality disorder was included from axis II. There is good evidence that personality disorders are strongly associated with use of mental health services, use of medical services (Reich et al., 1989), prognosis and responsiveness to treatment of axis I disorders (Reich and Green, 1991), and substantial impairment in functioning and subjective distress. There are important questions that...

Socioeconomic Status

Debate has raged over the nature of this remarkably consistent relationship between social class and mental disease do people with mental disorders slip down the social ladder due to their condition (social drift hypothesis), or does low social status play a causal role in the pathogenesis of psychopathology (social causation hypothesis) (Murphy et al., 1991) For adults, a notable study by Dohrenwend et al. (1992) found that the social drift phenomenon appears to be more important in the occurrence of schizophrenia while the social causation mechanism is a superior explanation for the occurrence of depression in women and antisocial personality and substance use disorders in men. Questions about the etiology of psychopathology in children and adolescents await similar analytical efforts. Our Chicago neighborhoods project has been designed in part to address another key question about the association between social status and mental disease to what extent is this association dependent...